Provider Demographics
NPI:1649791310
Name:ZETTERVALL, IAN (LPC, LADC)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:ZETTERVALL
Suffix:
Gender:M
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 BREWSTER RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-5212
Mailing Address - Country:US
Mailing Address - Phone:860-630-0820
Mailing Address - Fax:
Practice Address - Street 1:61 BRADLEY ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5103
Practice Address - Country:US
Practice Address - Phone:860-863-1937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-03
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001211101YA0400X
CT46.003558101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)